Just how fast is it?
Since the very first uses of radiation therapy as a cancer treatment modality, the established norm has been to deliver the total prescribed dose to patients over multiple sessions (between, known as “fractions”, typically lasting around 10 to 30 minutes. Treatments are divided into multiple units with a view to reaching an optimal balance between damage caused to the tumor, and radiation-induced toxicity to the surrounding tissue. (But what if there were a more efficient way to achieve this balance?)
“FLASH” has been challenging the convention of fractionation in radiotherapy since it was first brought into the spotlight by Vincent Favaudon’s research just over a decade ago, in 2014 (Favaudon et al, 2014). Pre-clinical studies have shown that while both FLASH and conventional radiotherapy treatments administered at equal doses achieve equivalent levels of tumor control, data suggested FLASH causes significantly less toxicity to the surrounding healthy tissue whilst delivering the treatment at an Ultra High Dose Rate within less than 100 milliseconds (Schuler et al, 2022).
By irradiating patients in a single session, for a fraction of a second, rather than over a number of weeks for up to 30 minutes at a time, the clinical application of FLASH couldwill be a gamechanger.
Since its creation, THERYQ has been focused on a single goal: pioneering the clinical application of this groundbreaking FLASH technology. By shortening treatments and drastically reducing the number of fractions, one of THERYQ’s aims is to reduce the psychological burden often experienced by patients undergoing lengthy conventional treatments. FLASH radiotherapy is not only a more effective solution, but a more compassionate one.
Standing up to cancer
The history of upright radiotherapy dates back to the conception of radiation in the therapeutic setting. Radiotherapy evolved to be delivered in a supine position due to the toxicities associated with radiation treatments in the 1950’s and 60’s before radiotherapy became intensity-modulated and image-guided. These toxicities resulted in patients being very unwell during treatment, often requiring inpatient stays in hospital and supine treatment was simply more comfortable for them when experiencing severe side effects.
If we fast forward to modern radiotherapy, tumor localization, image guidance, and adaptive radiotherapy are integral to the success we see and also in maintaining a better quality of life for patients by reducing side effects. So although the technology that delivers radiation treatment has evolved, the patient experience during treatment hasn’t changed significantly. Patients are still required to lie on a hard treatment bed, completely still whilst a large radiotherapy machine rotates around them.
Leo Cancer Care as a company grew from a simple goal, to make the experience of radiotherapy better for people, less vulnerable and less isolating. On re-exploring the concept of upright radiotherapy they have been able to develop technology that can image and deliver treatment whilst a person is seated or perched upright.
Working together
When Leo Cancer Care developed their technology they did so with the understanding that innovation in healthcare is difficult to negotiate but it is so important in improving the lives of those that it seeks to help.. This shared understanding and experience is what brought Leo Cancer Care and THERYQ together in their shared venture.
The two companies joined forces in October 2023 to develop the FLASHDEEP project, a radiotherapy device aimed at enabling the treatment of all solid tumors at any depth in a fraction of a second. As pioneers in their respective fields—upright patient positioning and FLASH radiotherapy—the collaboration brings together both parties’ expertise to develop a treatment that combines simplicity and efficiency to a degree that is currently unmatched in cancer treatment. The development and commercialization of this device will be a world first in cancer radiotherapy, offering new hope to patients who currently have no therapeutic alternatives and promises to deliver a radiotherapy experience that is truly patient-centered.
Cancer treatment and psychological disorders
Receiving a diagnosis of cancer is often a life-changing event and for many the psychological impact of that diagnosis and subsequent treatments will remain with a person long term. A recent study reported that 14% of people with cancer report anxiety which is almost three times as much as the general public. Other studies have shown this figure to be higher with around 21% of people with cancer showing clinical levels of anxiety (Goerling et al, 2023). The physical symptoms of anxiety include rapid heartbeat, sweating, dizziness and stomach aches. Mental symptoms include restlessness, irritability and difficulty concentrating (NHS, 2022). The consequence of these symptoms is often an inability to apply adequate coping strategies resulting in a negative impact on quality of life (Goerling et al, 2023).
The psychological impact of a cancer diagnosis is not limited to anxiety. 68.8% of patients showed depressive symptoms and 78.1% showed signs of stress. The levels of these increased amongst those with advanced disease, those requiring surgery, married patients, and those living more rurally (Alagizy et al, 2020). Despite such a high number of patients experiencing these symptoms only 15.5% reported being on medications to manage their conditions and only 10% sought advice from a mental health professional (Cancer Research UK, 2018). Nixon et al (YEAR) found that 24% of head and neck cancer patients had their first radiation treatment session disrupted due to anxiety with the National Cancer Institute (2016) acknowledging that any delays or unplanned breaks in radiotherapy treatment can result in an increased risk of disease recurrence and inferior rates of survival without disease recurrence.
Treatment-induced anxiety is well recognized however methods of management are typically under-funded and not always accessible for all patients. Attention therefore might be better focussed on identifying and reducing known triggers for anxiety. However, as the fundamental method of delivering radiotherapy has remained unchanged for almost a century, now might be the right to introduce something that challenges the norms of day-to-day treatment delivery. This is precisely what the collaborative work between Leo Cancer Care and THERYQ is doing.
Person-centred care is a model of care that focuses on the individual needs of a person with the belief that by meeting these needs patients demonstrate better compliance and have better treatment outcomes and better quality of life. The key areas of person-centred care are planning, communication, respect and holistic care (Coulter and Oldham, 2016). Oncology is a very multidisciplinary area of medicine with a patient negotiating a number of different treatment pathways in order to treat their cancer; this can make person-centered care challenging when effective communication is not practiced. Here a more paternalistic approach to healthcare is often employed especially within radiotherapy where a patient during their treatment set up and treatment are advised to lie completely still and allow the radiographer to maneuver them in exactly the same way every day for a number of weeks which can discourage patient autonomy.
Less time with us, more time for you
Tomastis et al (2023) explored the impact of hypofractionation in radiotherapy on departmental workflow and patient access to radiotherapy treatment. They identified that despite an increase in patients requiring radiotherapy over the last 10 years there has been a reduction in patient throughput due to the introduction of more complex treatment delivery methods, therefore patient waiting times have increased and there has been a greater burden on radiotherapy departments in terms of staffing and cost-effective management of reducing wait times. They did observe however that during the COVID-pandemic the introduction of hypofractionation regimes successfully resulted in a reduction in patient overcrowding in department and an observed optimal utilization of resources. It could be hypothesized therefore that by reducing fractionations further to a single treatment, as suggested with FLASH radiotherapy, that there will be greater machine availability as each patient will not require a treatment machine slot every day for 4-6 weeks. Greater machine availability could mean shorter wait times to commence a course of treatment. Forner et al (2021) discussed the increased psychosocial distress witnessed in patients who experienced increased waiting times during the COVID-19 pandemic with patients themselves identifying their high levels of stress being associated alterations to daily life and uncertain treatment timelines and fear of cancer progression.
When asked how daily treatment over a number of weeks impacted them, this patient said “Daily radiotherapy sessions over weeks impacted my life: physically, emotionally, exhaustingly. I would welcome a single treatment plan: physically, emotionally, energized… feeling less like a patient and more like a person. Quality of life matters: in and out of treatment”
This patient’s own views are reflected in the research collected by Lee et al (2024) which found that patients in an ultra-hypofractionation group showed better quality-of-life scores when compared to patients in a longer fractionation plan. With the promise of reduced side effects as well as less time absent from work, traveling to consecutive radiotherapy treatments as well as the financial burden of this increased travel it is easy to see how FLASH radiotherapy could improve on a patient’s quality of life in a number of different areas.
FLASHDEEP not only reduces the number of treatments a patient is required to receive, the treatment itself is ultra quick with treatment being delivered in less than 100 millisecond. In comparison with increasingly complex treatment plans in modern radiotherapy treatment the delivery time is closer to 4.8 minutes for IMRT treatment and 2.2 minutes for RapidArc (Oliver 2009) however the patient is expected to remain still from the start of patient set-up, during imaging and treatment deliver so is closer to 20 minutes and for some even longer.
A study into the patient set-up time utilizing Leo Cancer Care’s upright patient positioning system found that it took on average 5.0 minutes for two radiographers to set a patient up on their first day of treatment and 2.9 minutes for subsequent treatments. The mean time to unload patients was 0.6 minutes.
The author of this study and research Radiographer, Sophie Boisbouvier shared these thoughts on using the upright patient positioning system. “In upright position, it’s difficult to say that radiation therapists (RTT) set up the patient. The patient can naturally set up him/herself on the chair and become an actor of his/her treatment. Obviously, RTT remains crucial to help them and verify the position but as it is a more natural position, it’s easier and quicker for a patient to set up him/herself. During this setup time, patient and RTTs are physically close, at the same level and face to face, giving them an opportunity to discuss together and for the patient to be supported.“
Boisbouvier highlights two very important points here, patient participation and maintained eye contact.
A criticism of patient-centered practice in healthcare is the additional time and resources often needed to meet this (Guedes de Pinho et al, 2021). However, when presented with a treatment that takes a fraction of a second and with treatment set-up time being reduced considerably it could be argued that the technology developed by Leo Cancer Care and Theryq enables radiotherapy departments the additional time they need to ensure their patient’s individual needs are being met.
Patient in the driving seat
Patients have expressed a desire to have more control over their health and their treatments (Coulter and Oldham, 2016). By allowing a patient to set themselves up for treatment as observed by Boisbouvier in the clinical setting, they are able to feel some control over their treatment, their own bodies and can feel more empowered. Increased feelings of empowerment can reduce patient helplessness whilst simultaneously increasing self-advocacy which in turn gives patients the confidence to ask questions and express their thoughts and feelings increasing their satisfaction with their care and treatment (Salazar, L. 2018). These are all important components of person-centered care.
Boisbouvier’s research found that 94% of patients found it easy to get out of the upright patient positioning system compared to 60% of patients saying the same about a supine treatment position. With that increased difficulty getting out of a supine position comes with an increased need for assistance from radiotherapy staff reducing patients’ feelings of empowerment. The statistics from this study showed patients had increased comfort, feelings of stability, and easier breathing in the upright position compared to supine with a clear preference for this treatment position option.
When words aren’t enough
Research in healthcare highlights the importance of nonverbal communication in supporting patient’s well-being. By having a patient in the upright position the patient is in the optimal position to be able to observe that nonverbal communication such as eye contact and facial expressions have been shown to decrease anxiety whilst increasing patient compliance and understanding. D’Agostino and Bylund (2014) found that eye contact and mutual gaze are a primary component in patient-centered communication variables and have been found to impact patient-centeredness, rapport, physician awareness of patients’ psychological distress, and patient’s physical and cognitive functioning. Keck, Hubner, and Buntzel (2023) make the very important point that without face-to-face interactions between patient and therapist then patients who have a hearing impairment might not be able to give informed consent. Only 28.3% of hearing-impaired patients understood all verbal instructions given to them and they were more uncomfortable asking for clarification if they did not comprehend facts compared to hearing patients. 76% of patients with a hearing impairment desire eye contact during conversations. When receiving radiotherapy treatment in a supine position this is not possible as a patient’s field of view is reduced to the ceiling above them and emphasis is placed on staying completely still.
Upright & FLASH: Transforming Patient Experience
Through the simultaneous application of two innovative approaches to cancer treatment, Leo Cancer Care and THERYQ’s partnership on the FLASHDEEP project aims to significantly improve patient experience during radiotherapy. The “Upright FLASH” approach to treatment aligns a number of elements that contribute to the empowerment of patients from beginning to end of the single required session. By heavily mitigating the components of psychological detriment experienced during conventional treatments, the introduction of this modality will lighten the burden of radiotherapy and create a more human and convenient option.
The first FLASHDEEP device is to be installed at the leading cancer treatment center in Europe: Gustave Roussy in Paris, France. Eric Deutsch, the Head of their Radiotherapy Department, shared his thoughts on the benefits for patients of Upright FLASH radiotherapy treatment:
“FLASH radiation therapy in an upright position offers patients significant advantages, both physically and emotionally: it reduces side effects, minimizes the need for multiple hospital visits, and alleviates anxiety by providing a more comfortable treatment experience, ultimately improving the patient’s overall well-being and quality of life during their cancer journey.”
As Leo Cancer Care’s Upright solutions are integrated into radiotherapy devices worldwide, and THERYQ advances the clinical translation of FLASH technology, the future of cancer treatment is fast-approaching, with the first assembly of FLASHDEEP’s model set to begin in late 2025 at Lausanne University Hospital (CHUV).
Reference
Alagizy, H.A., et al. Anxiety, depression and perceived stress among breast cancer patients: single institute experience. Middle East Current Psychiatry. (2020) 27:29.
Boisbouvier, S., et al. Upright patient positioning for pelvic radiotherapy treatments. Technical Innovations and Patient Support in Radiation Oncology, 24: 124-130.
Cancer ResearchUK (2018) https://news.cancerresearchuk.org/2018/08/22/the-realities-of-cancer-mental-health-issues-and-changes-to-energy-levels-top-concerns-among-cancer-1/#:~:text=The%20new%20data%20reveals%20that,from%20a%20mental%20health%20professional.
Coulter, A., Oldham, J. Person-centred care: what is itand how do we get there? Future Healthcare Journal, 2016:3(2):114-116. Doi: 10.7861/futurehosp.3-2-114
Favaudon, V., et al. Ultrahigh dose-rate FLASH irradiation increases the differential response between normal and tumor tissue in mice. Science Translational Medicine (2014) 6(245), 245ra93-245ra93
Forner, D., et al. Psychosocial Distress in Adult Patients Awaiting Cancer Surgery during the COVID-19 Pandemic. Current Oncology. 2021, 28(3): 1867-1878. Doi: 10.3390/curroncol28030173
Goerling, U., et al. Prevalence and severity of anxiety in cancer patients: results from a multi-center cohort study in Germany. Journal of Cancer Research and Clinical Oncology. (2023) 149: 6371-6379
Guedes de Pinho, L., et al. Patient-Centred ACre for Patients with Depression or Anxiety Disorder: An Integrative Review. J. Pers. Med. 2021, 11(8), 776. Doi: 10.3390/jpm11080776
Lee, S. F., et al Randomised controlled trials on radiation dose fractionation in breast cancer: systematic review and meta-analysis with emphasis on side effects and cosmesis. British Medical Journal. 2024; 386. Doi: https://doi.org/10.1136/bmj-2023-079089
Oliver, M., Ansbacher, W., Beckham, W.A. Comparing planning time, delivery time and plan quality for IMRT, RapidArc and tomotherapy. Journal of Applied Clinical Medical Physics. 2009, 10(4): 117-131. Doi:10.1120/jacmp.v10i4.3068
National Cancer Institute. Missed Radiation Therapy Sessions Increase Risk of Cancer Recurrence. (2016). Available at: https://www.cancer.gov/news-events/cancer-currents-blog/2016/missed-radiation-therapy
NHS. Signs of an anxiety disoder. 2022. Available at: https://www.nhs.uk/mental-health/feelings-symptoms-behaviours/feelings-and-symptoms/anxiety-disorder-signs/
Salazar, L. The Effect of Patient Self-Advoacy on Patient Satisfaction: Exploring Self-Compassion as a Mediator. Communication Studies, 00(00): 1-16
Schüler, E., et al. Ultra‐high dose rate electron beams and the FLASH effect: From preclinical evidence to a new radiotherapy paradigm. Medical Physics, 49, 2082-2095
Gazis, N., et al. Simulation Dosimetry Studies for FLASH Radiation Therapy (RT) with Ultra-High Dose Rate (UHDR) Electron Beam. Quantum Beam Science (2024) 8(2), 13-13
Tomatis, S., et al. Twenty Years of Advancements in a Radiotherapy Facility: Clinical Protocols, Technology, and Management. Current Oncology (2023); 30(7): 7031-7042. Doi:10.3390/curroncol30070510
